Healthcare Provider Details

I. General information

NPI: 1720001878
Provider Name (Legal Business Name): JOSHUA SULLUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 FIFTH AVENUE
NEW YORK NY
10128
US

IV. Provider business mailing address

1136 FIFTH AVENUE
NEW YORK NY
10128
US

V. Phone/Fax

Practice location:
  • Phone: 212-410-5600
  • Fax: 212-876-3478
Mailing address:
  • Phone: 212-410-5600
  • Fax: 212-876-3478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number228478
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: